345002823-9-24-2021-25-AS-SCAA-C7736E-20210924175814

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 345002823
Report Date: 09/24/2021
Date Signed: 09/24/2021 05:58:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME:	WHOLESOME ELDERLY ON KIFISIA		FACILITY NUMBER:	345002823
ADMINISTRATOR:	FAAMUSILI, CHRIS		FACILITY TYPE:	740
ADDRESS:	6024 KIFISIA WAY		TELEPHONE:	(916) 670-2647
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	6	CENSUS: 3	DATE:	09/24/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Chris Faamusili, pending Licensee and Kim Bennett, Administrator		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a Pre-Licensing inspection due to a change in ownership. LPA met with Chris Faamusili, pending Licensee and Kim Bennett, Administrator and explained purpose of inspection. LPA confirmed there are currently (3) residents at the facility and (2) residents are receiving hospice services. LPA completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. LPA and pending Licensee toured the interior and exterior of the facility including the common areas, resident bedrooms (5), bathrooms kitchen, and laundry area/garage. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting throughout. LPA observed all resident bedrooms to be complete with required furniture, and the bathrooms to have the necessary grab bars and non-skid flooring as well as trash cans with lids. LPA observed sufficient 7+day non-perishable and 2+ day perishable supply of food and sufficient dishes, flatware and cooking pans. LPA observed sharps to be locked in the kitchen, medications to be locked in a cabinet nearby and toxins to be locked in the laundry area. LPA observed the smoke/monoxide alarms to be in working order, and the fire extinguisher to have been last serviced 8/5/2021. LPA observed sufficient towels, linens and hygiene supplies and complete first aid kits on hand. LPA measured the hot water temperature in the kitchen at 118* F. Resident/Staff binders observed to contain required paperwork. LPA observed board games and books on site. LPA observed (1) unlocked exit gate, the pool to be enclosed by a locked gate, and all exit doors to have alarms. Facility has working land phone line. LPA observed the following posted at facility: Resident Personal Rights, See Something Say Something and Ombudsman posters, Facility sketch with evacuation route, Theft and Loss Policy, Rights of Resident/Family Councils, Non-Discrimination notice, House Rules and various Covid-19 posters. cont on 809C..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: WHOLESOME ELDERLY ON KIFISIA	FACILITY NUMBER: 345002823
	VISIT DATE: 09/24/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA observed PPE, paper products and cleaning supplies on hand as well.

Comp III was conducted during today's inspection.

Pre-licensing is complete and this facility has no deficiencies. LPA to notify analyst in application unit of inspection being conducted.

An exit interview was conducted with pending Licensee. A copy of the report to be emailed following today's inspection due to technical difficulties.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2